Regional more beneficial than general anesthesia for hip surgery

USA: Regional anesthesia (RA) is more beneficial than general anesthesia (GA) for hip fracture surgery in frail elderly, concludes a recent study published in the Journal of Orthopaedic Trauma. GA adversely influenced in-hospital mortality, time to death, increased LOS (length of stay), and discharge to an institute rather than home.

Chunyuan Qiu, MD, the chair of performance improvement at Kaiser Permanente Baldwin Park Medical Center, in Baldwin Park, Calif., and colleagues conducted the study to determine the impact of anesthesia type on in-hospital mortality and morbidity for geriatric fragility hip fracture surgery.

“Nobody really knows which approach is better in these patients, but we think that if a patient is old and fragile and needs emergency hip surgery, then the choice of anesthesia makes a huge difference,” said Qiu.

For comparing GA and RA, the researchers identified patients from the Kaiser Permanente Hip Fracture Registry aged at least 65 and underwent emergent repairs between 2009 and 2014. the analysis excluded cases if they involved patients with pathologic fractures, bilateral fractures, prior surgery on the affected hip or multiple fractures treated simultaneously.

The final patient sample comprised 16,695 individuals from 404 physicians and 38 hospitals within the Kaiser Permanente system. Of these patients, 57.7% (n=9,629) received general anesthesia, 39.5% (n=6,597) received regional anesthesia, and 2.8% (n=469) were converted from regional to general anesthesia. Patients with incomplete (n=117) or missing (n=1,995) anesthesia information were excluded.

The researchers then analyzed data on in-hospital mortality, time to death, discharge disposition, and length of stay (LOS) among the following anesthesia types: general anesthesia (GA), regional anesthesia (RA), and intraoperative conversions from regional to general (Cv).

They found that:

• General anesthesia patients more frequently had valvular heart diseases, whereas more of their regional counterparts had chronic obstructive pulmonary disease.


• General anesthesia patients had a greater risk for expiring in the hospital and a lower risk home discharge than those who received regional anesthesia.


• Patients who converted from regional to general anesthesia also had a higher risk for expiring in the hospital than regional anesthesia patients; no statistically significant difference was found between these groups with respect to the risk for home discharge.


• Patients who started with regional anesthesia but had to switch to general anesthesia for whatever reason essentially got two hits instead of one.


• General anesthesia patients also experienced a shorter time to death and longer LOS before home discharge or to a health care facility than those in the regional anesthesia group.


• Patients who converted from regional to general anesthesia also had a shorter time to in-hospital mortality compared with the regional anesthesia group.


• No statistically significant differences were observed in LOS, whether the patient was discharged home or to a health care facility.


• The investigators also performed a sensitivity analysis, which revealed that both the general anesthesia and conversion groups had a higher likelihood of in-hospital mortality than regional anesthesia patients. For those who survived to discharge, general anesthesia patients had a lower likelihood of returning home compared with the regional anesthesia group.

These results do not promote an overall superiority of regional over general anesthesia, but rather demonstrate one technique’s benefits in a specific patient subset, the researchers point out.

“We were very surprised to find that mortality rates were so different between the types of anesthesia,” Dr. Qiu said.

For detailed study log on to doi: 10.1097/BOT.0000000000001035